A PhD study was carried out on comfort and health of workers in outpatient areas because hos-pital workers are generally less satisfied with comfort than patients and outpatient areas were understudied. To better understand differences in preferences and satisfaction of individuals, profiles were produced with Two-Step Cluster analysis, based on a questionnaire, responded by 556 outpatient workers, and building inspection of six hospital locations. Thereafter, interviews were performed to explain the preferences. As the COVID-19 pandemic started after produc-tion of the profiles, changes due to de pandemic were included. A gap between preferences and satisfaction was identified for all profiles. Also, those with similar preferences for social comfort (privacy, interaction, distraction) performed similar activities. Contact with others was for all profiles important, while satisfaction was overall high before the COVID-19 pandemic. Due to the shift to digital care during the COVID-19 pandemic, impoverished interaction was a main concern of the outpatient workers. In conclusion the profiles for social comfort show that preferences for social comfort are associated with work-related aspects and can change. The profiles may open a new horizon to accommodate for flexibility and variety beyond standardized solutions.Show Less
Type of the Paper: Peer-reviewed Conference Paper / Full Paper
Track title: healthcare design and change
Preferences and satisfaction with social comfort of outpatient workers in six hospitals before and during the COVID-19 pandemic.
AnneMarie Eijkelenboom 1,
1 AnneMarie Eijkelenboom; firstname.lastname@example.org; ORCID ID 0000-0002-7998-8773.
(to be completed by the editors)
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Journal: The Evolving Scholar
Submitted: 15 July2022
This work is licensed under a Creative Commons Attribution BY license (CC BY).
© 2022 [Name of the authors] published by TU Delft OPEN on behalf of the authors.
A PhD study was conducted on comfort and health of workers in outpatient areas because hospital workers are less satisfied with comfort than patients and outpatient areas were understudied. To better understand differences in preferences and satisfaction of individuals, profiles were produced with Two-Step Cluster analysis, based on a questionnaire, responded by 556 outpatient workers, and building inspection of six hospital locations. Thereafter, interviews were performed to explain the preferences. As the COVID-19 pandemic started after production of the profiles, changes due to de pandemic were included. A gap between preferences and satisfaction was identified for all profiles. Also, those with similar preferences for social comfort (privacy, interaction, distraction) performed similar activities. Contact with others was for all profiles important, while satisfaction was overall high before the COVID-19 pandemic. Due to the shift to digital care during the COVID-19 pandemic, impoverished interaction was a main concern of the outpatient workers. In conclusion the profiles for social comfort show that preferences for social comfort are associated with work-related aspects and can change. The profiles may open a new horizon to accommodate for flexibility and variety beyond standardized solutions.
Keywords: social comfort, hospital staff, COVID-19 pandemic, preference
While the pressure on hospital staff is increasing, due to staff shortage and the increasing complexity of tasks (Barker, 2011), staff is less satisfied with comfort than patients (Eijkelenboom and Bluyssen, 2019). Satisfaction with comfort can vary between different departments, such as inpatient wards or outpatient areas, due to different activities, duration of stay and building characteristics (Rashid and Zimring, 2008). As limited studies were found in outpatient areas, a PhD study was carried out on health and comfort of workers in outpatient areas.
Comfort was defined in this PhD study as a multifactorial construct, including indoor environmental quality (IEQ) and social comfort. This was done because several authors suggested that both the physiological perception of IEQ (thermal, indoor air, acoustic, lighting aspects) and social comfort aspects (privacy, crowding, distraction) contribute to satisfaction with the physical environment (Visscher, 2007; Shin, 2016). Also, personal, work and building-related aspects were included to capture a view that justifies for the complexity of the outpatient workers’ perceptions. The PhD study identified differences in satisfaction with room types between IEQ and social comfort, associations of building-related aspects with health complaints, changes in comfort due to the COVID-19 pandemic and profiles for IEQ and social comfort. As the social comfort profiles were mostly related to work activities, and these can change in future, this paper focusses on social comfort.
2. Theories and Methods
It is important to understand differences between individuals for improved wellbeing in hospitals, as the sensitivity to environmental stimuli can vary between individuals. For example, in a study on the perception of acitvity based offices, Hoendervanger, Ernst, Albers, Mobach, and Van Yperen (2018) indicated that satisfaction with the physical environment was related to differences in preferences for privacy between individual occupants. To justify for differences in preferences and satisfaction between individuals, profiling can be used (Bluyssen, 2019). While previous studies in hospitals mostly focussed on satisfaction with comfort aspects, understanding of the preferences can contribute to the design practice. Therefore, this paper aims to provide insights into differences in perceived importance and satisfaction between groups with similar preferences (profiles). Furthermore changes in social comfort, due to the COVID-19 pandemic, are explained.
This paper presents detailed information on social comfort and discusses the main results of social comfort, which were part of the PhD study.
2.2. Study design
A field study was conducted in two phases: a quantitative phase in the spring of 2019 and a qualitative phase in the autumn of 2020. This mixed methods approach was used to gain broad and in-depth insights into comfort and health of staff in hospitals. Only teaching hospitals were included, to avoid bias due to organizational differences between academic, general, and teaching hospitals. Three hospitals participated, all with the main and one smaller location.
In the spring of 2019, a digital questionnaire was distributed by the hospital organizations among 1.694 outpatient workers at six hospital locations. The questionnaire included validated questions on IEQ and health, based on OFFICAIR (Bluyssen et al. 2016), a translated set of questions on the perceived esthetical quality (Fisher, 1974) and a new set of questions on social comfort. These questions were based on literature. Also, the questionnaire comprised a new set of questions on preferences, related to the questions on IEQ and social comfort. The questionnaire was evaluated in a pilot study with outpatient workers of a general hospital. These outpatient workers were not included in the main study. Also, checklists were used to collect data of building-related aspects, such as enclosure of rooms, direction of lighting, finishing materials, HVAC-systems, potential pollutants, etc.
A representative group of the participants from the first phase was recruited for the qualitative follow-up. Semi-structured interviews were conducted in the autumn of 2020, during the COVID-19 pandemic. The semi-structured interviews included explanation of work activities, changes during the COVID-19 pandemic, preferences for IEQ and social comfort, and ranking of preferences. For comparison with the survey, the outpatient workers were asked to rank the comfort aspects that were used to produce the profiles.
Before the interviews, the participants were instructed to send photos of comfort aspects in their most frequently used rooms. These were used to support communication of the experiences and preferences (Wilhoit, 2017). A pilot test was performed with outpatient workers, who did not participate in the main study. The interviews were audio-taped with Microsoft Teams and transcribed verbatim.
2.3. Ethical approval
Participation was voluntary. The participants could only participate after their approval of informed consent. The data were stored on a secured server. The study design was approved by the Ethics Committee of Delft University of Technology in October 2018.
2.4. Data analysis
Data from the questionnaire were imported from Qualtrics XM platform into IBM SPSS Statistics 25. Data from building inspection were manually put into IBM SPSS Statistics 25. Building-related aspects were assigned to the respondents when the inspected variables were consistent. Consistency was identified with crosstabs of building-related aspects on different scale levels, such as organization, location, building-wing, room type, presence of a facade window, etc. The interviews were transcribed verbatim. Meaningful text fragments were manually put into Microsoft 365 Excel.
The main preferences and satisfaction were identified through descriptive statistics. Two-Step Cluster analysis was used to produce clusters, which were differentiated by preferences and satisfaction with comfort. This was done for IEQ and social comfort separately. For the profiles, all preferences, satisfaction, personal, work, and building-related aspects, were compared between the clusters.
Inductive analysis, according to the steps defined by Gioia (2013), was used to identify changes due to the COVID-19 pandemic. The codes from the inductive analysis were compared with the data of the individuals from the survey. See Eijkelenboom and Bluyssen (2020) and Eijkelenboom, Ortiz, and Bluyssen (2021) for detailed information on the study design and analysis.
The questionnaire was responded by 556 workers from outpatient areas at six hospital locations in the spring of 2019. The preferences and perceptions of those working at the various locations could be compared, as personal aspects, such as age or sex, did not vary between them (Eijkelenboom, Kim and Bluyssen (2020).
3.1. Preferences before the pandemic
Figure 1 shows the main preferences of the outpatient workers for social comfort aspects. Also, physical aspects, the size of the workplace and size of storage place, are included. The importance of the distinct aspects varied between the outpatient workers. For example, two third of the outpatient workers regarded contact with colleagues and patients among the three most important aspects for their work performance, while less than 2% regarded the size of storage place or no crowding in the building important. Another aspect that was only for a minority (less than 10%) important was the length of the walking distances. Aspects that were important for a large group were a safe workplace (over 50%), patient privacy (over 40%) and no distraction by noise (over 25%).
Figure 1. Preferences of the outpatient workers
The four social comfort aspects that were preferred by most outpatient workers, i.e., contact with colleagues and patients, safe workplace, patient privacy and no distraction by noise, were included in the Two-Step Cluster analysis. Also, satisfaction with the social comfort aspects was included. To reduce the number of variables for inclusion in the Two-Step Cluster analysis, the questions on satisfaction were reduced with Principal Component Analysis. This resulted in three components: interaction (contact and proximity), disturbance (distraction by noise, visual distraction, crowding at workplace and building, privacy of self) and sense of space (short walking distances, size storage place, size workplace, safe workplace) (Eijkelenboom et al. 2020). The cluster analysis resulted in three social comfort clusters (SC1, SC2, SC3). The preferences had a larger weight in the cluster analysis than (dis)satisfaction.
Figure 2 shows satisfaction and preferences for social comfort of those in different the clusters. The aspects that vary statistically were previously showed in Eijkelenboom et al. (2020). Overall, the differences between the clusters in preferences related to the principal component disturbance are larger than for the components related to interaction and sense of space. Dissatisfaction with interaction was lower than the importance for all clusters, while the dissatisfaction with sense of space, except a safe workplace, was higher than the importance for all clusters. Dissatisfaction with disturbance varied (P-value <0.05) between the clusters, except with crowding in the building. Dissatisfaction with contact varied, while dissatisfaction with proximity did not vary. Dissatisfaction with sense of space did not vary, except walking distances.
Figure 2. Preferences and dissatisfaction of the clusters
The social comfort profiles varied for work-related aspects, such as activities (based on Chi Square with Bonferroni correction, P-value <0,05), while only a few building-related aspects and personal aspects varied (Eijkelenboom et al. 2020). Those in SC1, who regarded a quiet workplace (no distraction by noise, no visual distraction, no crowding) more important than those in other clusters, were more likely to do concentrated office work and meetings (Figure 3). Those in SC2, who regarded the privacy of patients more important than the others, were more likely to work directly with patients, such as medical treatment, physical examination, diagnosis, and consultation. Those is SC3, who found a safe workplace most important, were more likely to do routine office work.
Figure 3. Differences in activities between the clusters. Detailed information can be found Eijkelenboom et al. (2020)
3.2. Preferences during the pandemic
In the autumn of 2020, during the COVID-19 pandemic, seventeen outpatient workers were interviewed to explain their preferences. This was done because of the heavy weight of preferences in the clusters, gaps between satisfaction and preferences, and limited literature on preferences. Outpatient workers from all clusters and all hospital locations participated, to gain a representative overview.
Due to the COVID-19 pandemic the number of patients, visitors and staff in the hospitals was reduced, and social distancing and mouth-face masks were obliged in the hospitals. Outpatient care was partly digital, using videocalls. Face-to-face contact occurred for physical investigation, consultation with seriously ill patients and depended on the department, such as oncology or paediatric care (Eijkelenboom, Ortiz and Bluyssen, 2021).
Figure 4. Main preferences, logic of ranking and changes
Figure 4 shows the changes of social comfort preferences during the COVID-19 pandemic, logic of ranking, adaptations of the building and other changes. The Figure shows that all these aspects could vary between the participants. For example, the caption ‘’Ranking logic’’ shows that all four social comfort aspects were for some of the participants most important. And the caption “Changed” shows that he main preference of some outpatient workers had changed since 2019, while for others it did not.
For some outpatient workers ranking of the importance of social comfort aspects was logic, while others perceived an overlap of contact with privacy, safety, or distraction. For them differentiation was illogical because they regarded these social comfort aspects interrelated or equally important. Furthermore, the importance of distraction, privacy and safety depended on the context, such as the different room types, and activities. For example, limited distraction could be unimportant in the morning when working at the reception desk, and important in the afternoon when working in the back-office, before and during the lock-down.
To limit infection risk during the COVID-19 pandemic, some small physical adaptations of furniture were executed, such as stanchions in front of the reception desk or a splash guard at the reception (Eijkelenboom, Ortiz and Bluyssen, 2021). Therefore, those working at a reception desk found it more difficult to support privacy of the patients, because the patients had to talk louder. Outpatient workers were concerned that personal information was audible for others in the waiting room. Those who moved to a renovated area or who were relocated, were more satisfied with comfort than in 2019.
Other changes, not related to the building characteristics of the outpatient area, were sensitization and working in other areas, e.g., testing of corona infections, or working at home. Those who worked from home, but also others who worked at the hospital, were missing face-face contact with patients and colleagues (Eijkelenboom, Ortiz and Bluyssen, 2021). They found face-to-face contact especially important because it contributed to their work satisfaction. Also, face-to-face contact was important for the quality of care. Nurses and physicians were worried to miss physical cues and to miss means to show their involvement. Reception workers were concerned that they could not help vulnerable patients when they only had contact via a telephone call. Also, the limited number of colleagues at the hospital was perceived to decrease safety for some outpatient workers. This occurred when patients showed aggressive behaviour or were impatient, when colleagues were not nearby.
The results provide insights into preferences and satisfaction with social comfort and changes during the COVID-19 pandemic. The results clearly show a gap between satisfaction and preferences, also within the profiles that justified for differences between individuals.
The number of participants was sufficient for the Two-Step Cluster analysis, according to simulation studies by Dolnicar, Grün, Leisch, and Schmidt (2014). A sample size of at least forty participants per included variable was needed, with a separation level of 0.0 between clusters. 538 participants were included for production of the social comfort clusters, while at least two hundred were needed (product of 5 variables included and 40 participants per variable, separation level 0.0). The sample of the interviews was representative, including outpatient workers of all social comfort clusters, divergent functions, room types, and all hospital organizations. The sample size was sufficient according to Guest, Bunce, and Johnson (2006) for saturation of the data, i.e., analysis of changes due to the COVID-19 pandemic. However, explanation of the profiles was complex, due to the changes by the COVID-19 pandemic. Caution is needed for interpretation of the results because the used methods did not allow for determination of causal relations. However, the study shows that main preferences for social comfort can change when measures to reduce the infection risk during an epidemic are taken. Also, the study design in two phases allowed to include data during the pandemic, in contrast to parallel collection of qualitative and quantitative data.
As preferences for social comfort of outpatient workers had changed during the COVID-19 pandemic, it can be suggested that social comfort preferences can be influenced by contextual changes. Hoeffler and Ariely (1999) suggested that a strong experience can contribute to the formation of a stable preference, while a flaw experience is more changeable. This might explain why the main preference of only a part of the outpatient workers had changed, while the same measures to reduce infection with the SARS-CoV-2 virus were taken in all hospitals. To increase the validity and usability of the profiles, it is recommended to further study the stability and strength of preferences for social comfort.
The differences in activities between the clusters, especially for concentrated or routine office work, versus diagnosis, consultation, treatment, and physical examination show that social comfort preferences can vary among those who perform different (combinations 0f) activities. by For those who did not find it logic to rank social comfort aspects, importance of social comfort depended on the context. It could be suggested that satisfaction with social comfort can be improved, by careful determination of requirements, and design that supports the different activities. A previous study with the same dataset showed that the activities varied also between the different room types, i.e., receptions, offices, consultation rooms, and treatment rooms. Satisfaction with social comfort was more likely to vary between room types than satisfaction with IEQ (Eijkelenboom, Kim and Bluyssen 2020). For example, those who work most frequently in a consultation room, were more satisfied with their own privacy than those in offices. However, while those in SC2 were more likely to work in consultation rooms than the others, and those in SC1 and SC3 were more likely to work in offices, their satisfaction with privacy did not vary. Furthermore, those in SC1 perceived more distraction by noise, than those in SC2 and SC3, while there was no difference in the perception of distraction by noise (P-value >0.05) between those working in offices or consultation rooms. Also, those in SC1 regarded it more important to have no distraction than those in SC3, while in both clusters they were more likely to work in offices. Furthermore, while those in SC2, were more satisfied with the aesthetical quality than those in SC1, those in SC3 were similarly satisfied with the aesthetical quality than those in SC2. Therefore, it can be stated that accounting for differences between room types in the design is relevant, but also profiles are needed to optimize social comfort.
Contact with others was important for those in all clusters and the dissatisfaction was low before the pandemic. As digital care increased during the COVID-19 pandemic, and face-to-face contact decreased, the outpatient workers experienced impoverished interaction. While there is yet limited information (Crawford and Serhal, 2020), this is in line with suggestions of previous studies. For example, Romanick-Schmiedl and Ragu (2020) suggested that face-to-face contact could support trust of the patients. The worries of the outpatient workers to miss physical cues, such as trembling fingers, were also found in this study. In contrast, Rosen, Joffe, and Kelz (2020) suggested that the quality of care could improve by digital care, as the patients could receive the diagnosis in the familiar environment of their home. These suggestions show that further study is needed on social comfort of patients and staff in relation to face-to-face and digital care, as digital care might continue because of future epidemics or other organizational reasons. Investigation of changes in work processes and the occupants’ preferences for social comfort, may contribute to design for an optimal fit of individuals and outpatient areas. New layouts can be designed, simulated, and evaluated iteratively, to assess whether the design supports the care processes and comfort. This can be done through collaboration of outpatient workers, policymakers, health sociologists, and architects.
Furthermore, it can be suggested that places that accommodate safely for face-to-face contact of hospital workers and patients need to be included in outpatient areas. These places can support informal exchange and trustful relations. Places for interaction with others may contribute to decreased work stress (Karanikola, Tampakis, Tsolakidou, 2020). For a safe place, that enables social distancing and face-to-face contact, it is important to take the occupant density into account during the design process (Awada, Becerik-Gerber, Hoque, O’Neill, Pedrielli, Wen and Wu, 2021).
This study offers detailed insights into preferences of outpatient workers for social comfort. The three profiles, which were strongly differentiated by distraction, safety, and privacy for patients, show differences in preferences and satisfaction before the COVID-19 pandemic. For all profiles, the importance of contact and satisfaction with contact was high. Furthermore, it was shown that multiple factors had changed during the COVID-19 pandemic. The satisfaction or preferences for social comfort had changed as well, especially the satisfaction with contact decreased. Overall, the profiles for social comfort show that preferences for social comfort are associated with work-related aspects and can change. The profiles may open a new horizon to accommodate for flexibility and variety beyond standardized solutions.
Data Availability Statement (if applicable)
The dataset is not publicly available, because of personal information of the participants. For information, please contact the author.
The main study was supported by Daikin Nederland and EGM architects and performed at Delft University of Technology, Faculty of the Built Environment, at the chair of Indoor Environment.
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